Objective
Telehealth in the ED seems counterintuitive. However, COVID-19 surges have led to crowding and increases in patients leaving without being seen (LWBS). This study evaluated the impact of a novel virtual telehealth initiative (virtual telehealth rounding or VTR) in the ED on the prevalence of LWBS dispositions during the pandemic and its effect on mortality and patient safety.
Methods
We conducted a cross sectional study on adult patients presenting to a level 1 trauma and tertiary referral center who were triaged to the waiting room. The trial of VTR took place for 107 days in December 2021-April 2022 and was operational for 65 days (8-hours a day). The remaining 42 days without VTR served as a comparison group. During VTR patients were triaged per usual care on arrival to the ED. Those patients with triage acuity categories II to V who were triaged to the waiting room were then evaluated virtually by a remote clinician (advanced practice providers such as physician assistants, advanced nurse practitioners, and third year emergency medicine residents) after their initial screening examination using a secure virtual health platform in a private cubicle in the ED waiting room. Patients were then reevaluated at 1-2 hour intervals if necessary. ED paramedics were available onsite to take vital signs, transport patients, and communicate directly with the onsite nurses and ED physicians. Patients were evaluated virtually via an iPad by the virtual clinician and provided an initial assessment. They expedited care by ordering labs, radiography, changing the patient’s triage category and determining early disposition according to usual clinical practice. Patients were then either left to wait in the waiting room, taken for radiography and/or blood work, or taken back to a room in the ED where they were seen by an onsite ED physician. The main outcome was the LWBS rate, including LWBS before and after triage, patients leaving against medical advice and elopements. Secondary patient outcomes included in-hospital mortality and improved patient safety via “great saves” defined as care that was urgently/emergently escalated by the virtual rounding provider.
Results
There were 19,958 patients in the analysis, 6,953 (35%) were evaluated via VTR and 13,006 (65%) received standard of care. Mean patient age was 50 years (SD20), 48 (95% CI 48-49) in the VTR group and 50 (95% CI 50-51) in the standard group. Females were 49%, with 3,489 (50%) females in the VTR group and 6,204 (48%) in the standard care group. Overall acuity levels at triage were II 24%, III 54%, IV 22%, and V 1%. Mean triage levels were 2.95 (95% CI 2.94-2.97) in the VTR group and 3.07 (95% CI 3.06 – 3.09) in the standard group. The proportion of LWBS was 565 (8%) in the VTR group and 3,246 (25%) in the standard care group (p<0.001). Overall, 27 (0.1%) of patients did not survive to hospital discharge, 7 (0.1%) in the VTR group and 20 (0.2%) in the standard care group (p=0.421). VTR clinician documented “great saves” in 5% of their patient encounters.
Conclusion
This novel approach to triage in the ED significantly reduced the proportion of patients with LWBS dispositions by 17%. Although in-hospital mortality was lower in the VTR group it was not statistically significant. Furthermore, VTR clinicians documented rapid escalations in care that may have otherwise been delayed or missed. This approach has the potential to improve patient care and provide relief from crowding.
No, authors do not have interests to disclose